In this description of my ongoing treatment with Will, a man who experienced severe, sadistic physical and sexual trauma during a pre-adolescence already characterized by loneliness and unresponsiveness, I attempted to bring attendees into the consulting room by providing microprocess from our sessions while weaving the patient's history into the narrative. During the course of the treatment Will began to practice autoerotic asphyxiation in an attempt to manage bombarding, assaultive traumatic images over which he felt little control. With a symptom as disturbing as this one for both patient and therapist, the therapist works to self-regulate as well as regulate the patient's over-stimulation and help him towards safety. I managed my own anxiety by seeking multiple consultations, and by recognizing the forward edge meaning in his behaviors and in the eroticized elements of the transference. A strong connection between Will and me and the emergence of an idealizing selfobject transference allow him to take in my protective, calming and shame-detoxifying efforts.

The process shared in this presentation highlighted my efforts to stay close to Will's affective experience. As a result, we collaboratively articulated an understanding of a symptom that recapitulated Will's trauma, as an effort to gain mastery and self regulate. Our connection allowed us to be together in the frightening places and for me to help articulate and organize his internal experience in order to facilitate greater self development including empathy for himself so that he is not destroyed by overwhelming shame, which along with overstimulation is an important driver of the autoerotic asphyxiation. While there is much work ahead in this treatment, Will has greater awareness of his own feelings, rather than experiencing only diffuse, relationship-destroying rage, has increased capacity to turn to others for understanding and comfort and has a significantly diminished tendency to dissociate both in and outside of sessions.

In my response to Denise Davis's paper, I considered the many questions one must ask oneself in determining how best to respond in clinical situations that require the extraordinary from us. My interest was to parse out whether the analyst's participation may inadvertently be a repeat of the trauma, a trailing edge concern, or whether something new, a forward edge, may be emerging. I asked the following questions; can we always know and trust our ability to distinguish a forward edge from a trailing edge? How do we make emotional contact and validate a patient's worth as a human being beyond his trauma? Regarding Denise's dramatic case, I expressed concern about this patient's wish to more directly involve his analyst in an aspect of his acting out of a very risky and potentially life-threatening trauma scenario. It seemed to me that joining him could potentially collapse a safe space for him to begin to reflect on the state of his selfhood and capacity for relatedness beyond the repetition of the trauma. My clinical read on the case was that the patient's precociously self-sufficient solutions to his early relational traumas made it difficult for him to allow Denise to make contact with him. I did not feel as though Denise would necessarily be pulling back from deepening involvement with him should she empathically and tactfully delay joining him in the aspect of the trauma enactment he was requesting. Rather, I suggested that opening a space for a full exploration of his desire and normal need could provide a compassionate disruption of his trauma cycle that pulled together embodied mindedness within a safe form of intimacy that did not risk his threatening his life.

Precis of the Discussion of Denise Davis' Presentation
David Terman, M.D.

Several important factors in the treatment of such severe trauma and abuse were discussed.

First, one must re-connect the needs and wished of normal development that were derailed and distorted in the abuse. That is, one must interpret the perverse symptoms with normal developmental needs. In this case, the normal developmental needs were those of developing a masculine self, integrating maturing sexual feelings and having an idealized masculine figure to accomplish all that. These normal needs became overstimulating, perverse, exhibitionistic sado-masochistic and homosexual fantasies and acts.

Second, one must detoxify the affects stimulated in the abuse. The therapist accepts the sexual feelings and the excitement without either stimulating or disapproving of the feelings and eventually contextualizing them in the developmental process. In addition, the therapist must also understand and interpret the confusion between sexual feelings and the need to experience a selfobject connection with the therapist. This is part of the process of desexualizing the selfobject needs.

Finally, the therapist is faced with frightening symptoms and the risk of either inadvertent death or suicide. These real possibilities may create intense anxiety in the therapist. Using colleagues or consultants in such situations, as Denise Davis did, is a useful and perhaps essential means of coping with these very difficult situations.

The therapist used and demonstrated all these elements in her work with the patient.

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